Diners Club Business Card Application

Transcription

1 Diners Club Business Card Application Please provide ALL information requested to avoid delays in processing the application. Please complete this form in BLACK pen and BLOCK CAPITALS. Before completing this application please consider whether the business and each Applicant complies with the following minimum criteria: The business has been trading for 2 or more years Each Applicant is aged 18 years or over, earns a minimum of $35,000 p.a and has a sound credit rating. Diners Club may need to call you to obtain further information to assist in assessing your application. BUSINESS Joint & Several Liability Central Billing 21 day payment terms $77 Rewards fee Main Card DC Only: XB Main Card DC+MC: XD Supp Card DC Only: XB Supp Card DC+MC: XDA00005 Business Information Company Registered business name ACN Trading name ABN/ARBN Business name to appear on Corporate Card (maximum of 21 characters including spaces) Trading address Suburb State Postcode Registered office address Suburb State Postcode Phone Fax ( ) ( ) Please select one of the following on the structure of the business: Sole Trader Partnership Private Company Trust Association Note: Please refer to the Identification Forms listing for the appropriate Identification Form(s) that need to be completed for your application. Industry or nature of business No. of employees Years in business Current sales volume per month $ Expected Diners Club Account expenditure per month $ Business Reference Accountants/Auditors If the business accepts payment by Diners Club, please provide Diners Club Establishment number Contact name Phone Fax ( ) ( ) Diners Club Card Program As part of my Business Policy, I authorise employees, should they apply, to be issued with: (Please choose ONE of the following and note that this will apply to Applicants ONE and TWO on this application) Diners Club Business Card ONLY OR Diners Club Business Card AND Companion MasterCard Card Rewards I would like to enrol in Diners Club Rewards Yes No Do you wish to have Reward points earned on Diners Club Business Cards allocated to: Individual Cardholder OR A nominated Cardholder (who must be Applicant ONE)* * All Reward points earned on Business Card(s) issued will be pooled to the nominated Cardholder, who will legally own the Reward points. Billing Cycle Please nominate a day of the month between 2nd and 28th on which you would like your Diners Club Monthly statement to cut: /of every month. Preferred mailing address Suburb State Postcode page 1 of 3

2 Applicant ONE must be a Director, Partner or Principal of the business If pooling Diners Club Reward points, Applicant ONE must be the nominated Cardholder. Applicant ONE Personal Information Title Surname Given names Preferred name and title on your Diners Club Personal Card (max. of 21 characters including spaces) Male Female Date of birth Driver s licence no. Marital status Nationality Residential address State Postcode Yrs/Mnths there Home phone / ( ) Preferred address (Mandatory - we will use this to send you statements and notices in relation to your account) Mobile phone Previous residential address State Postcode Years/Months there / Preferred mailing address State Postcode Own home outright Buying home (mortgage) Renting Living with parents Other Mother s maiden name Name of relative or friend in Australia not living with you Relationship Residential address of relative or friend in Australia State Postcode Home phone ( ) Current employment: Position/Title (Applicant) Yrs/Mnths there Occupation / Your gross annual income: $35,000-$50,000 $50,001-$75,000 $75,001-$100,000 $100,000+ Other cards held: Amex Visa MasterCard Others Do you currently have or have you ever held a Diners Club Card? Yes No If Yes, your account number 3 6 Applicant TWO must be a Director, Partner or Principal of the business Applicant TWO Personal Information Title Surname Given names Preferred name and title on your Diners Club Personal Card (max. of 21 characters including spaces) Male Female Date of birth Driver s licence no. Marital status Nationality Residential address State Postcode Yrs/Mnths there Home phone / ( ) Preferred address (Mandatory - we will use this to send you statements and notices in relation to your account) Mobile phone Previous residential address State Postcode Years/Months there / Preferred mailing address State Postcode Own home outright Buying home (mortgage) Renting Living with parents Other Mother s maiden name Name of relative or friend in Australia not living with you Relationship Residential address of relative or friend in Australia State Postcode Home phone ( ) Current employment: Position/Title (Applicant) Yrs/Mnths there Occupation / Your gross annual income: $35,000-$50,000 $50,001-$75,000 $75,001-$100,000 $100,000+ Other cards held: Amex Visa MasterCard Others Do you currently have or have you ever held a Diners Club Card? Yes No If Yes, your account number 3 6 page 2 of 3

3 Privacy Consents and Notifications By applying for this product, you consent as follows: In this section we/us means Diners Club Pty Limited ( Diners Club ) and our related companies that assist us to provide our services and you/your means all borrowers named in this application. Purposes for which we collect, use and disclose your personal information 1) We collect, use and disclose your personal information: to assess this application and future applications and to administer your credit facilities and related services; to conduct reviews of your facility; to comply with applicable laws both in Australia and overseas, including: a) the National Consumer Credit Protection Act; b) the Anti-Money Laundering and Counter-Terrorism Financing Act; c) State and Territory property legislation and other property-related laws (for example, to register and search for security interests); and for other purposes as listed in our Privacy Policy and our Credit Reporting Policy. If you do not provide us with the information we may not be able to assess your application or administer the products or services that you are seeking. 2) We usually collect your personal information directly from you. However, we may need to collect personal information about you from third parties for example, in order to assist us to process your application or to locate or communicate with you. 3) Where you have provided information about another individual, you must make them aware of that fact and the contents of this Privacy Consent and Notification, and have obtained their consent to make this disclosure to us. 4) Your telephone calls and conversations with a Diners Club representative may be recorded and monitored for quality, training and verification purposes. Disclosures of your personal information 5) We may disclose to, and obtain personal information about you from: Our affiliates, sales agents and organisations that carry out functions on our behalf including card schemes, mailing houses, data processors and collection agents; reward providers including Airline partners and their service providers; other credit providers; any signatory or guarantor to the facility for which you are applying; any broker, introducer, financial, legal or other adviser acting in connection with your facility or application; regulatory and tax authorities in Australia and overseas; credit reporting bodies (see Exchange of information with credit reporting bodies below); any insurer relating to your facility; organisations wishing to acquire an interest in any part of our business; and as further set out in our Privacy Policy and Credit Reporting Policy. Disclosures to overseas recipients 6) Some of the recipients to whom we disclose your personal information may be based overseas. It is not practicable to list every country in which such recipients are located but it is likely that such countries will include the United States of America, India, the Philippines, Malaysia, Hong Kong and Singapore. By consenting to us disclosing your personal information to overseas recipients, you agree that Australian Privacy Principle 8.1 shall not apply to the disclosure, meaning that Diners Club will not be obliged under the Privacy Act to ensure that an overseas recipient does not breach the Australian Privacy Principles and we will not be liable under the Privacy Act if the recipient does not act consistently with the Australian Privacy Principles. By completing this application you consent to such overseas disclosures. Exchange of information with credit reporting bodies and other information services 7) If you have made an application for consumer or commercial credit, or have obtained consumer or commercial credit from us, you agree that we can obtain credit reporting information about you from a credit reporting body (CRB) for the purposes of assessing any application for consumer or commercial credit and collecting payments that are overdue in relation to consumer or commercial credit. You also agree that we can obtain, from any business providing information about commercial credit-worthiness, commercial credit reports about you for the purposes of assessing applications for consumer or commercial credit. 8) We may disclose personal information about you (including credit information, such as details about the credit that we provide to you, your repayment history and any repayment defaults) to, and obtain credit reporting information about you from, CRBs. Our Credit Reporting Policy contains information about credit reporting, including the CRBs with which we may share your personal information, their contact details, the type of credit reporting information we share, and your rights in relation to them. Our Policies (including how to access and correct information and make a complaint) 9) You can view our Privacy Policy or Credit Reporting Policy on our website at dinersclub. com.au/privacy or obtain copies by calling us. These policies include information as to how you can access and/or seek correction of the personal information we hold about you. Our Privacy Policy and Credit Reporting Policy also contain information as to how you can complain about a breach by us of the Privacy Act (including the credit reporting provisions in Part IIIA and the Credit Reporting Code) and how we will deal with such a complaint. Your Marketing Communications Preferences 10) By completing this application you agree that we, our affiliate companies and their partners may use your personal information to keep you informed about offers relating to this product and other products, services and offers which may be of interest to you. They may do this by phone, mail, and SMS or other electronic messages (without an unsubscribe facility). These consents operate indefinitely and shall remain in effect unless and until you notify us that you do not want to receive such communications. If you do not wish to receive these communications please notify us in writing or by calling us. Note: If you have not told us that you do not wish to receive these communications by phone, you may be contacted even if you have registered your phone number on the national Do Not Call Register. Declarations and Authorisations Interpretation: In these Declarations and Authorisations, any reference to a defined term has the same meaning as in the Business/Corporate Card Terms and Conditions unless the context otherwise requires. Any reference to the business includes a reference to a company, partnership, joint venture, association, governmental agency, firm, body corporate, sole trader or other business entity. Diners Club Card Application (this section applies to you if you are the business or an Applicant) Application: By signing this form, the business and the Applicant: (A) request that a Diners Club Card(s) (Card) be issued to the Applicant; (B) warrant that all information in this application is true and correct and not misleading; (C) warrant that the Applicant is an employee of the business and has been identified; (D) agrees to provide Diners Club with current financial statements upon request (E) acknowledge that the business and the Applicant will be bound by the Business/ Corporate Card Terms and Conditions (which will be provided to each on approval of this application) on first use of the Card or the Card account; (F) agree that information about you may be used as described in the Privacy section in the Business/Corporate Card Terms and Conditions, and that where you provide information about any other individual on this form or later, you will make that other individual aware of the provisions of that Privacy section; (G) agree that the Card(s) is issued at the direction of the business and may be cancelled by the business at any time by written notice to Diners Club; (H) acknowledges that a commission may be paid by Diners Club to the person (if any) named on this form for introducing you to Diners Club. The amount of any such commission will be based either on your expenditure or the number of introductions made by the person and is unascertainable at the time of this application. Diners Club reserves the right to amend the terms and conditions relating to the Card at any time by notice to the Applicant. (I) If acting as trustee, represents and warrants that the trust has been validly established that it has all the requisite powers to enter into an agreement with Diners Club relating to the Diners Club Corporate Card, that the beneficiaries of the trust of which it is a trustee will rank as unsecured creditors of any accrued and unpaid entitlements and will not receive any preferential treatment as against other creditors, in the absence of any mortgage, charge or other security and in the event of any inconsistency between the Diners Club Business/Corporate Card Terms and Conditions and the relevant trust deed, the Diners Club Business/Corporate Card Terms and Conditions shall prevail to the extent of the inconsistency. The business must use its best endeavours to ensure that the Applicant complies with his or her obligations under the Business/Corporate Card Terms and Conditions, including by notifying Diners Club of any loss, theft or fraudulent use of any Card, and the business must take all reasonable steps to recover the Card from the Applicant upon its cancellation by Diners Club. The business must also take all reasonable steps to recover a Card from the Applicant, and must advise Diners Club to cancel the Card, if the Applicant ceases to be employed with the business. Liability: The business (and in the case of trusts, the trustee) and each Applicant agree to be jointly and severally liable for (A) all charges incurred by the Applicant arising from, or in relation to, the issuance or use of a Card (including any reissued or replacement Card); (B) any fees set out in the Diners Club Fee Schedule at the end of the Business/Corporate Card Terms and Conditions; (C) any fees or charges in relation to each Applicant s membership of Diners Club Rewards; (D) If your account is not paid in full within 21 days of your monthly issue date, a charge will apply which is the greater of $30 or 3% of the overdue amount on your account each month. Any points accrued for that statement period will be forfeited and not allocated to your Diners Club Points Record; and (E) any goods and services tax which may be payable by Diners Club in respect of fees or charges charged by Diners Club on the Card account or in relation to any Applicant s membership of Diners Club Rewards (if applicable). Diners Club Rewards (this section applies to you, in addition to the section above, as the Applicant is automatically a member of the Diners Club Rewards program) Application: By signing this application, the Applicant indicates a wish to enrol as a member of the Diners Club Rewards program, you, the Applicant, acknowledge that you will be bound by the Diners Club Rewards Terms and Conditions provided to you with a Card, on first use of that Card. Signature(s) Must be supplied by a person(s) on behalf of the business If the person is also Applicant ONE or TWO then they must sign again in the Applicant Signature section below. By signing below, you warrant to Diners Club that you have authority to sign this form on behalf of the business. If the business is a partnership, you also undertake to advise Diners Club immediately if the partnership is dissolved or restructured. If the business is a trustee, you also undertake to advise Diners Club immediately if the trust is settled or wound up. Where the business is a COMPANY/SOLE TRADER/partnership Signature of Director/Partner/Principal for and on behalf of the business Date Where the business is a Trust and the Trustee is an INDIVIDUAL Signature of Trustee or Partner for and on behalf of the business Where the business is a Trust and the Trustee is a COMPANY Signature of Trustee for and on behalf of the business Date Date Important notice to Applicant/Cardholder: Please read the Declarations and Authorisations above before signing below. It includes authorisations by you concerning the use and disclosure of personal information about you and certain terms concerning your Diners Club membership, your rights and obligations as a Cardholder and your Diners Club Rewards membership (if applicable). Liability for the Business Card Account: In consideration of Diners Club, at your request, providing the Business Card Account to the business and issuing Cards linked to the Business Card Account from time to time, you agree: (1) to be liable, and indemnify Diners Club on demand, for all charges on the Business Card Account (which includes all charges in relation to the use of a Card and/ or a Card account that is linked now or in the future to the Business Card Account). This liability applies whether or not any charge has been authorised by the business. (2) that your liability: (a) is a primary obligation and continues until all charges on the Business Card Account are fully and finally paid; (b) will not be released or discharged by any event, including the alteration of the composition of the business, any variation of the Business/Corporate Card Terms and Conditions, the release of the business or any other person from any liability or any Cardholder ceasing to be employed or engaged by, or otherwise connected with, the business; and (c) is independent of, and in addition to, any other of your obligations. If more than one Applicant signs below and/or any other person assumes liability for charges on the Business Card Account, each person is jointly and severally liable. Each Applicant MUST SIGN below Applicant ONE Date Position Applicant TWO Position Date Completed application forms should be returned to: e: corporatenewapps@dinersclub.com.au Mail: Diners Club International, GPO BOX 40, Sydney, NSW 2001 For further information call Diners Club Customer Service 24 hours a day on Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0007_0216 page 3 of 3

4 FATCA ENTITY SELF-CERTIFICATION FORM (FOR USE BY ACTIVE NFFES HAVING AN OFFSHORE DEPOSITORY ACCOUNT ONLY) To comply with U.S. tax information reporting and Foreign Account Tax Compliance Act (FATCA) requirements, Diners Club must obtain certain information about each account holder s tax residency and tax classification status. In certain circumstances, Diners Club may be required to share this information with relevant tax authorities. By completing and signing this Form, you are self-certifying that the entity is an Active Non-Financial Foreign Entity (Active NFFE) with an offshore depository account only. Please refer to the FATCA statuses listed in Part 2A of Diners Club s Guidelines for Completion of this FATCA Entity Self-Certification Form to determine whether the entity is an Active NFFE. If you need assistance in determining the entity s FATCA status or in completing this Form, please contact your tax or legal advisor. Part 1 Entity/Organization Details (1) Name or Entity or Organization (2) Country of Incorporation or Organization (3) Permanent Residence Address (Do not use a P.O. Box or an in-care-of address (other than a registered address)). (4) Country (5) Postal/ZIP Code (6) Mailing Address (if different from above) (7) Country (8) Postal/ZIP Code Is the organization a disregarded or a fiscally-transparent entity for U.S. tax purposes? If yes, please complete the appropriate IRS Form W-8 or W-9 located at Yes No 2A FATCA Status Part 2 Entity Status Please review the FATCA statuses listed in Part 2A of Diners Club s Guidelines for Completion of this FATCA Entity Self-Certification Form to determine the entity s FATCA status and check the appropriate status below. If the entity is an Active NFFE with an offshore depository account only, you need only complete this Form. You do not need to also complete the appropriate IRS Form W-8. 1

5 If the entity is an Active NFFE having a custodial account for holding securities, or if the entity has any other FATCA status, you should not complete this Form. You should complete the appropriate IRS Form W-8 or Form W-9 (if a U.S. entity). Active NFFE having an offshore depository account only (You need only complete this Form) Active NFFE having a custodial account for holding securities (Complete the appropriate Form W-8; do not complete this Form) Passive NFFE (Complete the appropriate Form W-8; do not complete this Form) Non-participating FFI (Complete the appropriate Form W-8; do not complete this Form) Participating FFI (Complete the appropriate Form W-8; do not complete this Form) Reporting Model 1 FFI (Complete the appropriate Form W-8; do not complete this Form) U.S. entity (Complete Form W-9; do not complete this Form) IRS Forms W-8BEN-E, W-8IMY, W-8EXP, W-8ECI and W-9 and their corresponding instructions can be found at 2B Beneficial Owner Status Please indicate your entity s U.S. tax classification status by checking the appropriate status below: Corporation Estate Central Bank of Issue Private Foundation Complex Trust Government Tax-Exempt Organization Part 3 Certification and Signature Active NFFE Certification By signing below, I certify that: The entity identified in Part 1 is a foreign entity that is not a financial institution; and Less than 50% of such entity s gross income for the preceding calendar year is passive income; and Less than 50% of the assets held by such entity are assets that produce or are held for the production of passive income (calculated as the weighted average of the percentage of passive assets measured quarterly) (See Guidelines for an explanation of passive income); or The entity meets any of the other criteria contained in the definition of Active NFFE in Part 2A of the Guidelines. Consent to Information and Document Sharing 1. I authorize Diners Club to provide, directly or indirectly, to any relevant tax or other governmental authorities, a copy of this Form and to disclose to such party any additional information that Diners Club 2

6 may have in its possession that is relevant to the entity s claims on this Form. I acknowledge and agree that information contained on this Form and information regarding income paid or credited to or for the benefit of the account(s) to which this Form relates may be reported to tax or other governmental authorities and that those parties may provide the information to the country or countries in which the entity is resident for tax purposes. 2. I authorize Diners Club to provide, directly or indirectly, a copy of this Form and information relating to the account(s) to which this Form relates, as required by law, to: (i) any person that has control, receipt, or custody of income to which this Form relates; (ii) any person that can disburse or make payments of income to which this Form relates; or (iii) any party authorized to audit or conduct a similar control of aforementioned persons for tax purposes. Under penalties of perjury, I declare that I have examined the information on this Form and to the best of my knowledge and belief, it is true, correct and complete. I further certify under penalties of perjury that: a. The entity identified on line 1 of this Form is the beneficial owner of all the income to which this Form relates and is using this Form to certify its status for Chapter 4 purposes, or is a merchant submitting this Form for purposes of Section 6050W; b. The entity identified on line 1 of this Form is not a U.S. Person; c. The income to which this Form relates is (a) not effectively connected with the conduct of a trade or business in the United States; (b) effectively connected but is not subject to tax under an income tax treaty; or (c) the partner s share of a partnership s effectively connected income; and d. For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the regulations. Furthermore, I authorize this Form to be provided to any withholding agent that has control, receipt, or custody of the income of which the entity on line 1 is the beneficial owner or any withholding agent that can disburse or make payments of the income of which the entity on line 1 is the beneficial owner. I agree that I will submit a new Form within 30 days if any certification on this Form becomes incorrect. The Internal Revenue Service does not require your consent to any provisions of this Form other than the certifications required to establish your status as a non-u.s. Person, establish your Chapter 4 status (if required), and, if applicable, obtain a reduced rate of withholding. Sign Here: Print Name: Date: (DD-MM-YYYY) I certify that I have the capacity to sign for the entity identified in Part 1 of this Form. 3

7 Identification Forms Please complete the identification form(s) relevant for your business or organisation. Identification forms are available on the following pages. Forms: (a) Identification Form - Individual & Sole Traders (b) Identification Form - Partnerships (c) Identification Form - Australian Companies (d) Identification Form - Trusts & Trustees (e) Identification Form - Associations (f) Identification Form - Co-operatives Are you a Sole Trader? 1. Complete Form (a). Is your business a Partnership? 1. Complete Form (a), Section 1, for one Partner (Regulated Partnerships) or each Partner (Unregulated Partnerships). For more than one Partner, please attach additional copies of the form. 2. Complete Form (b). Is your business an Australian Company? 1. Complete Form (a), Section 1, for each Director / Beneficial Owner. For more than one Director / Beneficial Owner, please attach additional copies of the form. 2. Complete Form (c). For more than four Directors / Beneficial Owners, please attach additional copies of the form. Is your business a Trust? 1. Complete Form (a), Section 1, for each Beneficiary / Trustee. For more than one Beneficiary / Trustee, please attach additional copies of the form. 2. Complete Form (d). For more than four Directors / Beneficial Owners, please attach additional copies of the form. Is your business an Association? 1. Complete Form (e). Is your business a Co-operative? 1. Complete Form (f). If you have any queries, please contact us 24 hours a day, seven days a week on

8 Form (a) IDENTIFICATION FORM INDIVIDUALS & SOLE TRADERS Section 1: Personal Details Surname Full Given Name(s) Date of Birth (dd/mm/yy) Nationality Occupation Residential Address (PO Box is not acceptable) Do you or an immediate family member hold a public office position? YES NO Yes (please specify position e.g. politician/diplomat) Section 2: Complete this part if individual is a sole trader Full Business Name (if any) ABN (if any) Principal Place of Business (if any) (PO Box is not acceptable) 2015 Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0201_(0314) page 1 of 1

9 Form (b) IDENTIFICATION FORM PARTNERSHIPS Section 1: Partnership Identifi cation Procedure 1.1 General Information Full name of partnership Registered business name of partnership (if any) Country where partnership established 1.2 Partnership Type (select ü only ONE of the following categories) Regulated Partnership (Go to Section 1.3 below) Unregulated Partnership (Go to Section 1.4 below) 1.3 Regulated Partnership (do not complete for Unregulated Partnerships) Provide name of professional association Provide membership details (i.e. membership of professional association number) Please complete the appropriate identifi cation and verifi cation form for one partner 1.4 Unregulated Partnership (do not complete for Regulated Partnerships) How many partners are there? 1. Full name of Partner Role in relation to partnership (i.e. CEO, Owner) Percentage ownership of the partnership Should there be more than three (3) Partners, please complete additional Identifi cation Form Partnerships for the additional partner(s) information. Please complete the appropriate identifi cation and verifi cation form for each partner. 1.5 Beneficial Ownership Details Only required if individual is not already listed in section 1.4 above. Provide details of ALL individuals who are beneficial owners through control of 10% or more of the entity or more, where applicable. Full Given Name(s) Surname % control (if applicable) If there are additional beneficial owners, please complete all details in section 1.5 in an additional form. It is noted that a full KYC form (Individuals) must be completed for all the persons listed in this section 2015 Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0203_(1115) page 1 of 1

10 Form (c) IDENTIFICATION FORM AUSTRALIAN COMPANIES Foreign companies, whether registered with ASIC or not, should use the FOREIGN COMPANIES IDENTIFICATION FORM. Companies incorporated in Australia should use this form. Please ensure all applicable fi elds are completed in full Section 1: Australian Company Identifi cation 1.1 General Information Full name as registered by ASIC ACN Date of Incorporation Registered office address (PO Box is NOT acceptable) Principal place of business (if any) (PO Box is NOT acceptable) 1.2 Regulatory/Listing Details (If the company is regulated or listed, select the relevant category and provide the information requested) Regulated company A company whose activities are subject to the oversight of a Commonwealth, State or Territory statutory regulator. In this context Regulated means subject to supervision beyond that provided by ASIC as a company registration body. For example: Australian Financial Services Licensees (AFSL); Australian Credit Licensees (ACL); or Registrable Superannuation Entity (RSE) Licensees. Full name of regulator providing licence (e.g. ASIC) Licence type (e.g. AFSL, ACL, RSE) Licence number Australian listed company Name of market/exchange Majority-owned subsidiary of an Australian listed company Australian listed company name Name of market/exchange 1.3 Company Type (select only ONE of the following categories) Private/Proprietary (companies whose name ends with Proprietary Limited, Pty Limited, Proprietary Ltd or Pty Ltd) Public (companies whose name does NOT include the word Pty or Proprietary; generally listed companies) 1.4 Directors (To be completed for Private/Proprietary companies only) How many directors are there? Full given name(s) provide full name of each director below Surname If there are additional directors, please complete all details in section 1.4 in an additional form Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0200_(1115) page 1 of 2

11 1.5 Beneficial Ownership (not required for Public companies as per section 1.5) Provide details of ALL individuals who are benefi cial owners through shareholdings of 10% or effective control of the customer entity. Full given name(s) Surname Role/Relationship with the customer % Holding / Control (if applicable) If there are additional benefi cial owners (shareholders and/or controllers), please complete all details in section 1.5 in an additional form. It is noted that a full KYC form (Individuals) must be completed for all the persons listed in this section. 1.6 Foreign Entity Ownership (To be completed for all companies, if any foreign entity ownership exists) Please provide details of ALL immediate entites any other entities in the customer s ownership chain that hold through one or more shareholdings, 10% or more of the company s issued capital and are located in a foreign jurisdiction. Please note the section is not applicable if the customer does not have any foreign jurisdiction entities in its ownership chain or if the customer s entity ownership chain are Australian only. Full name of foreign entity ownership company % Holding Country of formation / incorporation / registration If there are additional Foreign Entity Ownerships, please complete all details in section 1.6 in an additional form Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0200_(1115) page 2 of 2

12 Form (d) IDENTIFICATION FORM TRUSTS & TRUSTEES Please ensure all applicable fi elds are completed in full Section 1: Trust & Trustee Identifi cation 1.1 General Information Full name of the Trust Full business name of the Trustee in respect of the Trust (if any) Country where Trust established Government-issued identifi cation number and description for the Trust (if any) Registered Address (if any) 1.2 Type of Trust Tick Select ONE valid option from this section only Family Trust Unit Trust Hybrid Trust Charitable Trust Testamentary Trust Other type provide description 1.3 Trust Beneficiaries / Beneficial Ownership Details Do the terms of the Trust identify the benefi ciaries by reference to membership of a class? Yes Provide details of the membership class/es (e.g. unit holders, family members of named person, charitable organisations/causes) (Go to Section 1.4) No How many benefi ciaries are there? Provide full name of each benefi ciary of the trust and / or any Individuals that may directly or indirectly control the entity Beneficiary 1 Beneficiary 2 Beneficiary 3 Beneficiary 4 Full given name(s)/entity name Full given name(s)/entity name Full given name(s)/entity name Full given name(s)/entity name Surname Surname Surname Surname If there are more benefi ciaries, provide details on a separate sheet. For each benefi ciary complete the Diners Club Identifi cation Form for that benefi ciary s entity type. 1.4 Trustee Details How many Trustees are there? provide full name of all Trustees below Trustee 1 Trustee 2 Trustee 3 Trustee 4 Full given name(s)/company name Full given name(s)/company name Full given name(s)/company name Full given name(s)/company name Surname Surname Surname Surname If there are more Trustees, provide details on a separate sheet. For each Trustee complete the Diners Club Identifi cation Form for that Trustee s entity type Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0202_(1115) page 1 of 2

13 1.5 Settlor Information Full name of the Settlor of the Trust * *Information not required in the following circumstances: Material asset contribution to the Trust by the Settlor at the time the trust was established was less than $10,000; OR The Settlor is deceased; OR The Trust is: a managed investment scheme registered with ASIC; or a managed investment scheme not registered with ASIC and only has wholesale clients and does not make small scale offerings to which section 1012E of the Corporations ACt 2001 applies; or registered and subject to the regulatory oversight of a Commonwealth statutory regulator in relation to its activities as a trust; or a government superfund 2015 Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0202_(1115) page 2 of 2

14 Form (e) IDENTIFICATION FORM ASSOCIATIONS Section 1: Association Identifi cation Procedure 1.1 General Information Full name of Association Full name of the following (or equivalent in each case): Full given name(s) of officer (if applicable) Surname Chairman Secretary Treasurer Provide an ID number issued on incorporation (eg. registration/incorporation number) (if any) 1.2 Association Type (select üonly ONE of the following categories) Incorporated Association Go to Section 1.3 below. Unincorporated Association Go to Section 1.4 below. 1.3 Incorporated Association (select ü and provide ONE of the following.) Principal place of administration Address (PO Box is NOT acceptable) If a principal place of administration is provided go to Section 2.1 Incorporated Associations Form Verification (no need to complete Section 1.4 for Incorporated Associations). Registered office Address (PO Box is NOT acceptable) If a registered office is provided go to Section 2.1 Incorporated Associations Form Verification (no need to complete Section 1.4 for Incorporated Associations). Name & residential address of the Public Officer (or President, Secretary or Treasurer if there is no Public Officer) Full given name(s) of officer (if applicable) Surname Position Residential Address (PO Box is NOT acceptable) If a Public Officer and their residential address is provided go to Section 2.1 Incorporated Associations Form Verification (no need to complete Section 1.4 for Incorporated Associations) Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0204_(1115) page 1 of 2

15 1.4 Unincorporated Association Principal place of administration (PO Box is NOT acceptable) For the member who is signing on behalf of an unincorporated Association fill out the Identification and Verification Form - Individuals. 1.5 Beneficial Ownership Details Only required if individual is not already listed in sections 1.1 and 1.3 above. Provide details of ALL individuals who are beneficial owners through control of 10% or more of the entity, including voting rights and power of veto, where applicable. Full Given Name(s) Surname % control (if applicable) If there are additional beneficial owners, please complete all details in section 1.5 in an additional form. It is noted that a full KYC form (Individuals) must be completed for all the persons listed in this section 2015 Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0204_(1115) page 2 of 2

16 Form (f) IDENTIFICATION FORM REGISTERED CO-OPERATIVE Section 1: Registered Co-operative Identifi cation Procedure 1.1 General Information Full name of registered co-operative Provide ID number issued by relevant registration body (if any) Full name of the following (or equivalent in each case): Full given name(s) of officer (if applicable) Surname Chairman Secretary Treasurer 1.2 Address Information (selectü and provide ONE of the following) Principal place of operations Address (PO Box is NOT acceptable) If a principal place of operations is provided go to Section 2: Registered Co-operative Verification Procedure. Registered office Address (PO Box is NOT acceptable) If a registered office is provided go to Section 2: Registered Co-operative Verification Procedure. Name & Residential address of the Secretary (or President or Treasurer if there is no Secretary) Full given name(s) of officer (if applicable) Surname Position Residential Address (PO Box is NOT acceptable) 2015 Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0205_(1115) page 1 of 2

17 Form (f 1.3 Beneficial Ownership Details Only required if individual is not already listed in sections 1.1 and 1.2 above. Provide details of ALL individuals who are beneficial owners through control of 10% or more of the entity, including voting rights and power of veto, where applicable. Full Given Name(s) Surname % control (if applicable) If there are additional beneficial owners, please complete all details in section 1.3 in an additional form. It is noted that a full KYC form (Individuals) must be completed for all the persons listed in this section 2015 Diners Club Pty Limited ABN Diners Club is the registered trademark of Diners Club International Limited used and registered throughout the world. DCC0205_(1115) page 2 of 2